Browsing Doctor of Nursing Practice (DNP) Projects by Subject "Older people"
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Implementation of a Pneumococcal Immunization Standing Order Protocol in Long-Term CareProblem & Purpose Streptococcus pneumonia is a significant cause of morbidity and mortality of adults who are immunocompromised and of advanced age. It is the standard of care to vaccinate all high-risk adults (18-64 years) and adults 65 years and older with two pneumococcal vaccines (Centers for Disease Control and Prevention [CDC], 2015). However, pneumococcal immunization rates remain below the HeathyPeople2020 target goal of 90% nationally and locally (Office of Disease Prevention and Health Promotion [ODPHP], 2019). The objective of this quality improvement (QI) project was to implement the Immunization Action Coalition (2017) pneumococcal standing order protocol to increase the percentage of adult patients screened for vaccine need by 90%, and percentage of total residents vaccinated according to CDC recommendations by 10%. Methods The strategy of this QI project was to educate registered nurses to implement a pneumococcal standing order protocol, in a privately owned, 120-bed, long-term care (LTC) center in suburban Maryland. The design of this QI project was based on the diffusion of innovation theory, the 4 pillars practice transformation program (4 Pillars), and the Mobilize-Assess-Plan-Implement-Track (MAP-IT) process model. Weekly frequency distributions were used to examine the screening and vaccination rates, and a chi squared (X2) test was performed post intervention to examine the significance of intervention on vaccination rates. Results The total number of LTC residents (n=100) were White (66%), Black (32%), other (2%), with an average age of 83 years. Pneumococcal immunization rates increased from 56% pre-intervention to 82% post-intervention, and screening rates for vaccination need increased from 0% to 100%. A chi-squared test for independence indicated a significant relationship between vaccination status and implantation of the SOP intervention (p = 0.046, df = 1, n = 100). Conclusions This QI initiative showed that a systematic process change is feasible and can improve pneumococcal vaccination rates in a single institution. The findings may not be applicable to centers without an electronic medical record software to document immunizations or dedicated QI team. Ongoing work should focus on the perceived self-efficacy of LTC nursing staff to effectively implement a behavior change, and skills to provide strong recommendations for immunizations.
Stopping Elderly Accidents, Deaths and Injuries: Fall Prevention for Community-Dwelling Older AdultsProblem & Purpose: Falls are the leading cause of death due to injury among older adults, yet most older adults who fall fail to report falling to their provider. Lack of routine fall screening and management among community-dwelling older adults places them at risk for future falls and injuries. The purpose of this 12-week quality improvement project was to implement the Centers for Disease Control and Prevention’s Stopping Elderly Accidents, Deaths, and Injuries protocol in a primary care office to screen older adults for falls and address modifiable risk factors for those at increased risk. Methods: A literature review supported the protocol in reducing falls among older adults. Publicly available resources were adapted into training presentations and case scenarios for providers and staff. Staff screened eligible older adults during their office visit. Providers assessed gait and balance for those with a positive screen and identified fall risk (low, moderate or high). Moderate- and high-risk patients received a risk assessment and fall plan of care. Protocol steps were recorded on checklists reviewed weekly by the project leader to evaluate protocol adherence. Ongoing chart reviews, case scenarios, and a mid-project training session reinforced the protocol. Data was analyzed in three four-week time intervals with a goal of 80% adherence to all protocol steps. Results: The majority of protocol steps remained above goal over all time intervals or improved with training. All moderate- and high-risk patients received a fall care plan, despite risk assessments dropping below goal in the final interval. Moderate-risk patients were difficult to correctly identify. Overall protocol adherence was highest for low-risk patients (97%) and lowest for high-risk patients (80%) compared to moderate-risk (81%). Conclusion: With continued staff education and protocol reinforcement, the Stopping Elderly Accidents Deaths and Injuries protocol can be successfully implemented in the primary care daily workflow. Protocol adherence may be complicated by fall risk level. This project’s results support the 2019 modified protocol in removing stratified risk levels. Barriers to implementation include lack of protocol reimbursement and time to complete the protocol. Future studies should assess effectiveness of the protocol in reducing falls at one-year follow-up.